A 79-year-old woman is brought to the office due to recurrent falls. Over the past year, the patient has become increasingly unsteady while walking and has had several falls. The patient has had no headaches, vision changes, nausea, or vomiting. Medical history is significant for hypertension, for which she takes losartan. Vital signs are within normal limits. Cardiopulmonary and abdominal examinations are unremarkable. Neurological examination shows normal cranial nerves and fundoscopy. There is increased tone and hyperreflexia of the lower extremities. Sensation to light touch and vibration is intact. When instructed to walk, the patient moves slowly with small steps and a wide base; she takes several steps to turn around. CT scan of the brain is shown below. This patient's symptoms would most likely improve with which of the following?

Question

A 79-year-old woman is brought to the office due to recurrent falls.  Over the past year, the patient has become increasingly unsteady while walking and has had several falls.  The patient has had no headaches, vision changes, nausea, or vomiting.  Medical history is significant for hypertension, for which she takes losartan.  Vital signs are within normal limits.  Cardiopulmonary and abdominal examinations are unremarkable.  Neurological examination shows normal cranial nerves and fundoscopy.  There is increased tone and hyperreflexia of the lower extremities.  Sensation to light touch and vibration is intact.  When instructed to walk, the patient moves slowly with small steps and a wide base; she takes several steps to turn around.  CT scan of the brain is shown below.  This patient's symptoms would most likely improve with which of the following?

Quizplus · Accepted Answer

This patient with recurrent falls has hyperreflexia and a wide-based gait. In association with the CT of the head demonstrating ventriculomegaly out of proportion to cerebral atrophy (eg, normal sulci), this presentation suggests normal pressure hydrocephalus (NPH). NPH is characterized by abnormal cerebrospinal fluid (CSF) accumulation and results in increased ventricular size without persistent elevations in intracranial pressure. ventriculomegaly out of proportion to cerebral atrophy Symptoms of NPH are classically described as a triad of urinary incontinence, cognitive impairment, and gait abnormalities. However, all 3 features are not required for diagnosis; in fact, only gait dysfunction, typically the most prominent symptom, is mandatory. In addition, upper-motor neuron signs, such as lower-extremity spasticity, hyperreflexia, and extensor plantar responses, may occur. The diagnosis is confirmed with high-volume lumbar puncture, which allows for both confirmation of normal opening pressure and gait testing. Improvement of gait function after the CSF removal is diagnostic. Alternatively, a temporary lumbar drain may be placed to assess for gait improvement over a period of days. Definitive therapy is ventricular shunt placement to divert excess CSF into the abdomen (ventriculoperitoneal shunt) or heart (ventriculoatrial shunt). (Choice A) Acetazolamide is used to treat patients with idiopathic intracranial hypertension (ie, pseudotumor cerebri). However, this typically occurs in young, obese women and is characterized by headache, vision change, and papilledema. Ventriculomegaly and gait dysfunction are unexpected. (Choice B) Cholinesterase inhibitors (eg, donepezil) are used to treat Alzheimer dementia. Despite generalized brain atrophy (eg, hydrocephalus ex vacuo) being common, ventriculomegaly without sulcal enlargement suggests NPH. In addition, hyperreflexia is unexpected. (Choice C) High-dose glucocorticoids are used in the treatment of multiple sclerosis, which can cause upper motor neuron signs and falls but typically occurs in young women with relapsing and remitting symptoms rather than the progressive symptoms seen in this patient. Ventriculomegaly is unexpected. (Choice E) Levodopa and carbidopa are used to treat Parkinson disease (PD), which can cause gait abnormalities. However, although shuffling is common in PD, the gait is usually festinating (short, quick steps). In addition, PD typically causes a pill-rolling tremor and cogwheel rigidity. Educational objective: Normal pressure hydrocephalus is characterized by abnormal gait, urinary incontinence, and cognitive impairment; however, only gait dysfunction is required for diagnosis. Neuroimaging demonstrates ventriculomegaly out of proportion to cerebral atrophy. The diagnosis is confirmed with high-volume lumbar puncture demonstrating improvement of gait with cerebrospinal fluid removal. Definitive treatment is ventricular shunt placement.

A 79-Year-Old Woman Is Brought to the Office Due to Recurrent